 several designated pharmacies that are HIV centers of excellence and what those are is those are specialized pharmacies where the pharmacists have additional training in HIV prevention treatment. We do medication therapy management. We'll do a one-on-one consultation sitting outside with the patient to answer any of their medication related questions. We can also refer them to social services, psychological services. We work with the community organizations and we're just here to learn more and promote our relationships and learn how we can better serve the community. And if you want brochures about what their program does, they're out on the exhibit tables up there. Hello my name is Yemba Samantha. I work with UT Health Science Center. We are the party of the Ryan White Program and the name of our organization or agency, South Texas Family AIDS Network. My name is Ana Escamilla and I am the medical case manager with Central Med. I'm Rachel Gonzalez. I'm the Director of Specialty Services at Central Med Center as a clinic and we have a routine testing program at Central Med. We've been implementing it since August, September 2011. And Central Med is one of your local federally qualified health centers. Hi my name is Alana Martinez and I'm a project coordinator at the Health Collaborative and we work closely with the Ryan White Program. My name is Tanya Burris. I'm the Director of Clinical Operations at the FACTS Clinic. We are doing routine testing. I'm so glad there's so many UHS people here. I'm Yvonne Venegas. I'm the Manager at the FACTS Clinic for the case managers. So we work directly with the HIV AIDS patients. I'm just kidding. My name is Matt Poe. I'm the routine HIV testing coordinator for University Health System. I work out of the FACTS Clinic under Tanya. Hi I'm Sarah Walker and I'm one of the nurses over at the University Southwest Clinic. Hi I'm Aurelia Hernandez. I'm a physician assistant and I'm with St. Mary's University. Thank you. Look at the diversity we have. I think you guys ought to give yourselves a round of applause. Thank you for being here. I'd like to introduce my panel this afternoon and when we talk about linkage to care and what's happening in San Antonio, we're really getting local. I think you saw this morning from Judge Wolf the overview of the importance of what this is. Then from Dr. Holly who was wonderful talking about why he does it in Beaumont and what drives him to do that. He said that hope was one of his greatest elements. Man if we could if we could bottle his positive attitude and just sprinkle it in every one of the hospitals we have here, we've had this problem licked. Then you heard from Dr. McCarthy again who's from Houston and their system of how they've set up to do routine testing and their trauma system and their emergency room. I thought you'd like to get a little bit of a local flavor. What are the resources and the major resource that we have and I think you heard earlier from Isabel Clark that they had funded two routine testing sites in San Antonio. One is at Centro Med which Rachel spoke about. It's there all of their clinics and how many do you have? 11 that do the routine testing including the one in Comal. Right. So it's the local ones in San Antonio and one in Comal County. So we've got a rural reach with that and then I'd like to turn it over just a few minutes to back to my Bob C twins back there and that would be Matt and Tanya to say just a little bit. I'm going to start with you Tanya to talk a little bit about the program. Matt I don't care who starts about what's here. We've started routine HIV testing July of 2010 primarily out of our emergency center and our two major urgent cares which are the Express Med at the hospital and the Express Med downtown or the Robert Brady Green. I'm sorry I'm having a brain fart. We've since expanded to our two university family health cares university family health care southeast and southwest. You saw the numbers for 2012. Our incident rate is continually 0.91% running about a 60-40 split 60% previous 40% new. All age ranges my youngest is 16 my oldest has been 63 from high-risk factor groups and from what they perceive as no risk factor groups. So it's the program works takes a lot of work to get it up and running to gain provider confidence. My personal experience I notify patients who test positive through my program. I also do quite a bit of the staff education through personal experience with that. The public does not have a problem with being tested long as it's done on a routine basis. They have a problem with it when they're behind the door with the provider and they're they're saying I need to check you for HIV when you're telling the general community that we're doing it as a routine test. No one no one is offended no one has any prejudice towards it and they all agree to it. So it's um I can I can besides you know the general population they'll accept it. Dealing with providers and past prejudices is actually quite a hassle when you're dealing with anyone in the medical community. What they perceive needs to be done and what they're used to focusing on is it's quite a battle to get that sort of thing changed. I just have to stand up I can't sit down. So what I have to say is a lot of what Dr. McCarthy talked about it in Houston are some of the same issues that we looked at. So educating the providers bringing it home why this is important. Every year now initially I think what were our testing numbers we strobe the very first year we were going to test 76 between 60 and 70 thousand that was our goal. The first year that we implemented testing getting everything done it was substantially lower it was 1500 all right. But that's hitting at the stone stay you know stay with stay with it that's what I got to say if you're if you're starting programs. Interestingly enough we started to go back and look at some of the patients that we had tested positive newly out of the emergency room and one that sticks with me and I always use this as an example so if you've heard it before bear with me. We had a patient who had 11 visits to the emergency center okay so we can't figure out what's going out what's going on with this man. He was diagnosed I believe with acute viral syndrome is what we could find he was referred to Hemalk where Hemalk drew blood and did an HIV test and we were able to get him into care. So it's right we give him a medical home we test him in the emergency center we link him in Matt has one of the best linkages into care in the state of Texas we're at 88% he does one heck of a job we go out and we find patients we talk to a men patient we talk to him out patient but we're doing a great job on getting them in of course we'd like that number to be a hundred and we're working every day to identify and link but the point of the matter is is stay with it everyone that we test and identify you're saving that possible transmission in the community and you're saving money because you know if you find them and get them into the clinic we're keeping them out of the emergency room with PCP and readmits down the line so thank you for being here. As for those of providers or associated with other outlined clinics or you know providers offices test your patients even if you don't think that your patients need the test test your patients and I think you'll be surprised. Thanks okay you heard it straight from the horse's mouth on how it works here in San Antonio then um what our system is now once they've identified them where can they go where can they go and the link to care what's available in care who's out there well first of all we have Metro Health Department San Antonio Metropolitan Health District and most people don't know that San Antonio Metropolitan Health District is the public health authority for the city and the county so throughout the whole region where we go because there's no county health department it's San Antonio Metropolitan Health Department and so talking a little bit about the disease intervention specialist which is job is to go out and look and link and find the find them and follow up I'm going to turn it over to Sian you're going to introduce the other person that you brought with you from Metro Health. Thank you Sian. My name is Sian Hill I am the field operations manager for Metro Health so that means I am over the entire public health follow-up team and that would include the DIS which are the disease intervention specialists. They're responsible for going out and locating persons that are infected or suspected of being infected with an STD under HIV. Once they locate that individual they're then responsible for conducting an interview or obtaining a field blood so that we can run additional tests. In that interview they will identify partners suspects and associates that we will then go out and attempt to locate to also render a test for. To my left is Valdemar Gonzalez he is one of our disease intervention specialists but he's also an OB GYN. I'm going to let him talk for a second. Okay well thank you. Hello everybody. DIS disease intervention specialist is not for everybody it's a hard work to do. I've always been in the field a medical field I come from Mexico I'm OB GYN from Mexico I'm working for being here but meanwhile I'm working of course in metro health department gave me the opportunity to work with them so I'm working hard on that and we know that the best way to fight some disease is not the best treatment it's the prevention of that disease of course so the work for the DIS is trying to find the people before that infection will attack that person and believe me it's hard. Why? Of course because the nature of the HIV and the target population who are at a high risk to have the HIV well not everybody it still is the stigma that everybody they don't want to talk to them or they are once they know that they are HIV they are afraid to you know do even being close to them there are some people who don't accept or they're homophobic so for have this job it's hard. Now once we found the patient which finally decides to get tested for any reason if they want they went to the emergency room or for a routine checkup or because he wake up and feels the feeling needing to get tested and happened that came positive well that's when we enter in the picture we need to talk to that patient we need to educate that patient we need to let them know that they're not going to die because of that infection because right now HIV is considered chronic disease it's a lot of treatment and a part of all that we need to convince them to give away something really private for them who are they sexual partners if somebody totally strange for me and something just suddenly you ask me with who am I sleeping with well what do you care well it's not your business well yes it's hard and you know what yes that's what we do every single day not just in the clinic we are the ones that we are active trying to prevent this infection and the hospital at the hospitals at the private doctors at the public settings well I consider those places yes really good but those are passive places where the people just go there as needed maybe they are don't know what is going on well that's when we need to go practically take a car and look for that people knock at the door if we happen so we know where does they live and try to let them know in the most private setting what is going on we have so many very different situations every patient is totally different sometimes the patient is 17 years old the person who opened the door is the mother and why are you looking for my son from where you come from well you need to go around all those stones and you know what man you know I come from the city of San Antonio first I need to talk to your son is health information that I need to talk to him once I talk to him if he let me I need to talk to you too and sometimes they accept other times they don't accept and I just try to get the most information from them so I feel sometimes they're like a CSI because practically when the patients came oh well I had sex well because that's something that I love from my job always we are talking about sex when they yeah when they came to our clinic okay with who you had sex you're in the last six months uh with four okay from those four with how many were male how many female and we go in detail for on each one okay the first one what's his name you know Raul okay Raul what well I don't know where do you met him at the bar what bar okay he's over here do you know phone number no do you know what he drives no okay let's pretend that he owes you a hundred thousand dollars how do you find him oh well uh I met him at his apartment okay where where is that apartment I don't know okay guide me through how I can get there and they goes okay go 31 by rixby and then turns there is an apartment second floor the the door the second door the right that's where he is okay how he looks like because I don't want to tell Raul's father which happens also names is Raul to tell you so all that's what that's what we do in a single day daily basis right now this morning I I just saw a guy who sent uh we received that person from some out from from Bear County it came from region I don't know from the north of Texas Amarillo let me say and the information that I received is is a young boy 17 years old Mr. John and he was partner partner is somebody who have sex with another person and we know that other person had syphilis this case was syphilis so we look for Mr. John that age more or less he only knew about what street he lives so we have the sources to look into that program we look for the street how many Mr. Jones lives at that particular age well three matches okay well on the description because we ask everything they say that they have tattoos all over the body all right so this morning I went I knocked in three different in the three different doors uh it it was under 18 so right now they are already in the house because they don't have classes so the first one it was nothing the other one it was not there the third one there you go it was skinny it was shaved a lot of tattoos John yes I need to talk to you okay well I drew the blood because besides all that you need to be able to draw blood okay and in any situation it could be in sidewalk and the car and the parking lot in the house dark you have to be able to do that so yes I took the blood I just coming from the health department I send the blood up I got the result because we got the results in one hour guess what yes he was positive right away because at the moment I took the blood okay I got the the information from him Mr. John oh yeah Mr. Gonzalez yes well have you ever had syphilis no well now you do you need to come to get treated oh okay don't tell me who was the one who told you well you know what I cannot tell you just be prepared because what we're gonna ask you once you come to our clinic I cannot take the treatment to you you need to come now to the clinic to get treated just be prepared when you come over here to the clinic we're gonna ask you with who you've been sexually active during the last year okay and yes okay well the same way that we are protecting the information from the other person we're gonna protect your information so that's why and that was an easy one that was an easy one there are too many that they know already what is going on we find we find that the homosexual community here in San Antonio is too tight they have their own ways to communicate between each other sometimes they know what is going on about their HIV status they just don't care other ones are more responsible and they gave us the names we tried to get the whole information actually we tried to get as much information about the partners to be interested in being treated sometimes we already know who is going to be positive in the next two months why because that person once he tells us all the information we have the database from all over Barack County so we know who is positive who is negative unfortunately we cannot tell him hey from the five partners that you gave me for our HIV positive it just mattered of time that you came positive the only thing that we can do is tell him you know what right now you are negative in the next two months I need to see you here again for a new test because you were playing with fire and right now is your HIV negative but it's no guarantee that in the next two months you're going to still negative sometimes they get it sometimes they don't get it and they still playing really bad so yes it's a hard it's a hard work that we do every single day it's not just for HIV it's for syphilis it's for chlamydia it's for gonorrhea when syphilis goes up we know HIV goes up okay syphilis is an open door for the infection patients with syphilis have two chances easier for them to catch the HIV virus and persons who don't have syphilis but yes it's a hard labor that we do every single day many people from outside and the community they don't know about us they just said I didn't know that you come over here are you the sex police well kind of kind of yes and sexy police as well yes so yes we are at the first step we are we are at the first step of the old channel when the HIV is going on in the city is a hard labor again I would like to have more people doing the prevention for the HIV making aware that what is going on in the community but still I was talking with somebody and what would you do if somebody is trained totally stranger okay I'm a page in front of your house knock the door nice to meet you my name is Mr. Gonzalez I'm looking for Mr. George okay I'm Mr. George I have the information I come from metro health I have the information that you might be exposed to HIV or syphilis of course everything is confidential and before I tell that information to you I was already see if nobody else is listening what would you say what do you think about it sometimes I I put in issues on the person that I'm interviewing well they're right what a hell are you what are you doing in my home right well yes it's something that we do and I just uh we like to remember every time that we're trying to look for help when we find that person and we try to send them uh to get services well sometimes it costs a lot of field basis try to find him try to get the test on try to okay identify him and then when I try to send refer him to any place for get services well I have an appointment next two weeks next one week or or actually right now I don't have any complaints with nobody okay I just want to be sure but uh it's hard labor to get those patients and convince them to get received the proper care it's hard to help somebody who doesn't need doesn't want to be helped okay so that's what we do in a daily basis I don't know if you have any comment any questions complaints with her okay with the my question when Dr. Mengele was talking about the women there is the access to care and women are finding it more difficult to get the care that they need and then my personal thought and having done this for so many years is that if you have a woman that is of lower economical status and there is a man providing any percentage of care for her and her children she is not going to deny him access to her when he wants to have sex with her she's going to have sex because there could be a consequence of I won't pay the light bill if you don't and then if he's on there's that other that down low factor so if he's secretly having sex with men or he's going to the bathhouse or whatever other activities he has going on then there's there goes the risk for that woman that could be her only partner but not necessarily he is and for that reason I think you have older men sleeping with younger women and then the other way around and then it's still that that down low factor the men that don't consider themselves to be gay MSM and they have families at home they have long-term girlfriends or wives or whatever have you there's increase we see a lot with the sex workers and San Antonio as you all probably know has a huge drug issue methamphetamine we get so many coming through our clinics and my question I don't get to interact with the patients very often but when I do I know there's a distinct purpose and so I always go in and it's kind of hard what's in your heart is what comes out of your mouth and I'm just gonna say it I love the Lord so when I approach it it's from a whole another level in perspective and I always try to meet the need I'm wanting to find out what can I do for you what are you prepared to do what are you willing to do and what are you crying out for because I'm sitting here I'll give an example in particular there was a young lady and she did not want to receive treatment for syphilis and she wasn't allergic to penicillin so our thought was it's been very difficult to get her we need to bicker big is by sylin which is what we give for syphilis and she didn't want these shots so I was trying to get an understanding of why her heart was so hard because there was just such a strong resistance there and one of the things she said I've been up for three days so I I knew why she had been up for three days but I wanted her to tell me why she had been up for three days so then I could find a door in to try and address the other issue that I could clearly see was going on well I've been smoking meth for for three days so I wanted her to tell me more about that addiction and when we got right down to it she her heart was so hard but at the end of that conversation she was crying because I was able to penetrate that place of need she just really I don't know that anybody had ever told her I love you or I want to help you I don't really know that she'd ever heard any of those things but in that moment I just wanted to be that person to say okay yes we need to treat this syphilis but tell me what else can I do for you what do you need from me who can I call what other help can I get you and then first finding out and I don't share this very often but I'm the daughter of an addict so I understand that that whole piece having gone through the alanon and I wasn't the one that could sit there and say oh yes I'm the daughter of an addict and this is what I need that just wasn't her okay me that wasn't her so I do understand that whole piece and I needed to know from her how can I help you what do you want me to do and when it was all said and done she really was tired because that's the first thing you got to find out when you're dealing with addiction are you tired because you cannot help someone that's addicted to something that does not want to be helped it's a waste of your time and so she really did and her grandmother was there and there were some other things so I was able to to help her but these people are young um and they're heroin addicts and as long as I've been doing this I'm still blown away but I still cry I guess I'm a wuss I have a I'm very sensitive so when I see this and I'm thinking I'm 39 years old as of last Sunday yay me but they're they're like 16 and 15 and they have track marks and sometimes I leave the room to go cry so that I can come back and be able to really fully address it but I got to go get that out first because I'm sad that you know this is their life and this is what's happening to them what was the other I talked so much I think another element with that but we don't admit to in San Antonio is human trafficking yes and that's not a choice of some people and I do know you can literally trap sometimes those that have been with these uh Coyote who brings them across and then abandons them and they've been raped along the way and so they feel like garbage or throw away once they get here having no resources of where to go and so prostitution is one of the places that they go and people say sex workers as if that in all instances is by choice and for a lot of women in particular in San Antonio given our very high poverty rate and given the immigration and the human trafficking that's happening now it is not and given their age and then the social networking what are you doing on that yes we are trying it's very hard at metro health but we are trying with the city manager and our program manager to get handles names on the different websites the atom for atom just all the different ones that men are frequenting and trying to we go in as normal not as the metro health but when we're trying to find someone we'll log in and maybe the OP which is the original patient gave us the P1's name which is the partner and then we go in and we try to have a conversation with that person online it's kind it's very difficult because they have all these they've got to come up with a way to do the firewalls and I don't think any of us are just trying to go and hang out on the site but it benefits us to be able to go in and find the people that we're trying to find and then the in spot some of you may be familiar with in spot but in spot is a tool that we can use to send email messages to partners and they actually have their own little logos and pictures you can kind of pick one that you want to use or you can design one yourself but you send a message and because it's so catchy when it comes through people have a tendency to open it and read it for that reason because it can colorful and it's you know it's like like her yeah that's what it is but in any event they read them and then it prompts them to call and then we can start that conversation and possibly get them in for for testing and our treatment or we can send one of the DIS to do what we call a field blood are there any questions for DIS everything you wanted to know about sex but we're afraid to ask in San Antonio Underground right okay yes sure grinder grinder and mocos and mocospace mocospace the kids use that one a lot yeah they use that one a lot Adam for Adam all social media places use the mic yes we we asked for the how do you call it not the nickname for the screen the screen name the screen name or the username and that way well we have one one access to houston we need to triangle the information well we have this this screen name we send it to houston and after 24 or 48 hours they send us back because i think they they can send an email or contact but we personally we cannot do it we don't have the power to do it and even grinder and the other applications we we have no access sometimes and it happened to me that the even the patient when they saw oh i have said well this is the picture and they saw it to me let me bring up they bring up facebook or or yeah maybe most of the time facebook and i saw him that happened that that guy i saw him in the clinic last week okay so well it's one person less that i have to but now that person didn't give me the name or the person that was here so something is wrong and then they talk about policy one of the policies around is the access that health departments or city and county systems need in order to be able to look at and this is going to sound funny play with or play around with those kinds of social they're past they're popping up almost faster than we can keep up but because of anti-pronographic policies at universities city and county governments it can be an impediment for the specialty that is needed at this level and that's a policy issue that we need to get around but sometimes it takes us so long to get around it how many other how many other young people have gotten infected by the time we can get a policy done i want to move on to our own program which i am the program manager for run by bear county department of community resources and our division of community health and introduce our hiv planner uh allison elmer she just recently got married and so i forget her always to call her by her other last name and it's bay law and so she's going to do her presentation here you go allison it's a freeway well first we need to stop all the way to bring the person in the green second step i can take a police officer and make him come to get to you so everybody you can have it stated uh all right uh that's what i can do yes i bet it's that way to bother me but i think we'll have a policy issue some clinics and this is what we're trying to move forward we're trying to get a mobile we're trying to get a mobile unit um there's one dallas has one i actually came from dallas and what i can say about that mobile unit is it works so well in attracting people um people would call in and ask where's the mobile van because they could easily access it rather than coming to to the clinic and so when you have a one stop shop and that's one thing one of the things that we have working against us and we are working diligently to try to get this changed we don't have anyone that can treat in the field so when you find a crack addict a heroin addict or someone that does not dance to our music i can tell you to come see me at three you'll be there i told them to come see me at three it might be three next week it just doesn't work like that and so we need a one stop shop we need to be able to treat them when we find them the other thing we don't have is the ability to transport our dis use the city vehicles but they cannot transport in them so when we find these individuals so that's two things working against us we can't treat them nor can we transport them so i'm relatively new here um haven't been here a year yet and these are just some of the things that i've identified and i'm working really hard to try and get those things changed otherwise the syphilis outbreak that we're in the middle of i won't be able to get a handle on it we and that's what we need everyone's help with this thing this has been the toughest of my career so far because i'm asked a lot of questions that i just don't have answers for because i have from what i know in my experience i have these things working against us and so for some of you these are things you need to advocate for the budgets for these things and the policies to change for these things and that starts with awareness and even though this is a small group now all of you know two things that she needs and what her wish list is in order to get the syphilis epidemic down okay allison so what i'm going to talk about today is how clients receive services after they've been identified um because a lot of clients who are tested hiv positive don't have health insurance and don't have other means to get treatment services uh these are some of our topics that we're going to go over briefly next slide so i work for bare county as the charlene we're known as the administrative agency or the grantee for ryan white funds we have ryan white funds parts a and b and we'll differentiate the parts in just a second we contract with agencies to provide services in your packet later on in the presentation you'll see all the agencies that we contract with we must monitor services to make sure that they're of high quality we also have to write grants to maintain the service system our biggest grant is from the federal government and it's about four million dollars so we have to write grants each year to get that money we also have to provide trading and i am the hiv planner there's usually two of us but there's only one right now and what i do is identify needs gaps in services and barriers to care next slide uh as you can see this is our service area it's the whole region eight so it goes from eagle past texas to victoria well actually beyond victoria texas so there's 28 counties in our service area uh those are listed alphabetically not by a region we actually have three regions uh the uvalde area the san antonio area and victoria area uh obvious uh the san antonio area has by far the most hiv cases probably close to 5000 in our area victoria is the next with about 140 cases and then eagle pass has 96 cases or so eagle pass has actually had a fairly substantial increase in uh the number of diagnosed victoria has been kind of stable but they keep getting people who move to victoria just out of the blue from different places and then san antonio has had a very large increase in the number of newly diagnosed in the last couple years uh the ones bolded are bercomo guadalupe and wilson and those are eligible for ryan white part a funding everybody else is eligible for ryan white part b funding and we'll kind of touch on the differences in a second so next slide please um as you can all see we have these hiv 210.org the colors on the slide we're missing red so my whole presentation's in red as you can see hiv 210.org is a website that is sponsored by the san antonio planning council uh the planning council is a planning body that comes together it can be up to 30 people right now it's like 20 or 21 and they're all defined positions so we have people who are substance abuse providers mental health providers people living with hiv uh a third of our planning council has to be people living with hiv and this board was established in 94 and what they do is they help determine what services are needed in the area uh so they do needs assessments like right now we're doing a needs assessment for mental health and then we're going to do one for substance abuse uh they also set the allocations uh so they decide well this year uh pharmacy is like really important because there's all these new medicines and medicines are very expensive and we have all these people coming into care we need to fund it at a higher percentage than we did last year same with medical care or you know the food bank's gotten really big lately we don't need to fund food as much as we used to so that's what the planning council does does that make sense basically okay so i would like for y'all to check this out sometime hiv2ten.org is the website of the planning council and the cool thing about the website is it has an interactive resource guide so that red resource guide is actually on the website uh and there's like about hiv and there's also vignettes or videos of people who have hiv or doctors talking about hiv and we're doing it to get the word out more and destigmatize hiv so it's it's not as taboo so people are on there talking about how they were infected or what it means to live with hiv and also if you get if you want to all of our needs assessments are on the website and all of our minutes and everything like that are on the website and also it shows where the free hiv testing is yes uh has everybody heard of rhinelight okay so we don't need to go there uh so the rhinelight program is the federal federally funded program that provides treatment and care services for people who are hiv positive it is the largest disease specific program in the united states however it is not the largest payer for people who have hiv medicaid and medicare are however the rhinelight program receives about two billion dollars a year from the federal government and that covers every single state in the union and all the not all the territories like the virgin islands and guam and Puerto Rico and what have you and the district of Colombia received part received rhinelight funds as i was mentioning earlier the rhinelight legislation is broken into five different parts part a part b part c part d and part f there is no part e there was but it was never funded so it doesn't matter uh part part e or what would have been party was actually for occupational exposure but it was never funded part a is for areas that are hard hit by the epidemic so dallas houston for for warren san antonio uh washington dc new york there's quite a few areas that receive party funding part b funding is the funding for all the medications through the age drug assistance program and also for every state in the union and the territories received part b funding the part b is actually the largest part of the rhinelight program by far part c which is what central med receives is for early intervention services and other outpatient medical care they can do medical nutrition case management there's a number of things they can do under part c part d is for women infants children and youth uh and they started out as a demonstration project and were the ones who were able to help reduce the transmission between mother and child and now it's like very very small and then part f is kind of like a whole big training program it's they do dental training they do age education training centers they'll come you know with that funding they go out and not the federal government themselves but different organizations go out and do trainings about hiv so that's what part f is uh if you want to learn more about rhinelight and the rhinelight program you can go to have.hersa.gov and you can actually look at the timeline and everything so next as we haven't mentioned yet it was started in 1990 and has been reauthorized a number of times and now we're in 2000 well actually we're in 2013 so it was reauthorized in 2009 as a rhinelight hiv treatment extension act and what was going on in 2009 is the federal government said hey we have good treatment we need to find people early because back in 2009 they estimated 21 of people came into care late or came and did not know their hiv status and they said you know with all this treatment it that is not as effective once someone's had hiv for many many years so it's much better to find someone early that's where you get the routine testing because the idea that people are going you know to the doctor or the emergency room and getting hiv tested there is a lot better than you know when they're in the emergency room for an opportunistic infection 10 years down the road so that's where we're at now um so the federal government likes acronyms this is called the early identification of individuals with hiv or aids also known as IHA and this is mandated by the federal government in the rhinelight legislation and we are required to link with other agencies that provide testing to ensure people are being tested for hiv the rhinelight program pays for very very little amount of testing because we're not really supposed to that is why we have to link with other agencies in order to provide testing and the idea is you know once we link with them they can link people into care and get people into care quicker and make sure that they follow them and ensure that they are in care um so as I said the 21 percent is actually closer to 18 percent so we have made a difference in finding people earlier so more people are aware of their hiv status now than they were any questions so um very briefly the eligibility for rhinelight will vary from area to area what i'm going to talk about is for our area so if you have clients who came from houston and said hey they provided this service in houston and i could be up to 500 percent of the poverty level i don't know if that's true uh why why can't you do that here because the rhinelight program is very unique in that we can make our own eligibility rules as long as people are hiv positive and of low income so we define what low income means the planning council does uh so you have to be hiv positive to be rhinelight eligible or related or affected to someone who is hiv positive some services can be provided to you also for financial clients must be added below 300 of the federal poverty level except for the categories of case management where you could be of any level uh but we don't really see a lot of millionaires coming into the clinics getting case management so uh they could they could uh residency clients must live in one of the 28 counties to receive services uh and rhinelight must be the payer of last resort so if a person has medicaid or medicare it's expected that you would charge medicaid or medicare for those services and not ryan white uh however if a person is a veteran a veteran and val eligible you do not have to make that person go to the va because of different um discriminations uh at the va over time with the like the don't have to tell and everything um they are allowed to receive services at the fax clinic or at central med uh even though that they would be eligible at the va that's the only exception and say i want ryan white care because i don't want to go to the va and we would be obliged to take care of hello okay i fixed it okay uh so we actually find six agencies uh in our 28 county area the alamo area resource center uh which is in san antonio that's their that's their front desk number uh central med uh the san antonio uh santa rosa clinic in san antonio and also the san antonio street clinic in new bronfills the new bronfills clinic only provides services on tuesdays uh but they're looking on tuesdays as of right now uh the san antonio aids foundation uh university health systems the fax clinic uh victoria city county health department which is in victoria texas and the maverick county hospital district which is an eagle pass uh those are all of our service providers um as a note all hiv positive clients can self refer to care so you could give this number any of these numbers to a client and they would be able to self refer to care uh but they do need to bring the following proof of hiv positivity proof of income some sort of id a social security card however services will not be denied to anybody who is not who is uh not a legal resident and also proof of insurance if they are insured so um i'm not going to go through all of these but in your packet which is in your portfolio thingy that thing uh it lists all the service categories that we fund and where you can access those services so like outpatient ambulatory medical care i have a description of what it is it's primary medical care in an outpatient setting uh one thing i didn't discuss earlier is we we don't pay for it we cannot pay for hospitalization legislatively we would be in a lot of trouble if we started paying for people's hospitalization the whole point of the ryan white program is to keep people out of the hospital so uh outpatient ambulatory medical care is provided at uhs central uh victoria and maverick county and so you can see all of the services that we provide and not all services are provided in all areas like victoria substance abuse is not provided because we don't have with the limited allocation of funding for that area we don't have enough money to pay for some of those types of services and uh like mental health services um psychiatric services aren't provided in the rural areas because it's hard to find a rural provider for psychiatric services um and what have you so that's that's that's any questions on the ryan white program you're gonna have a talk yes i appreciate that well one of the categories that she had up there was early intervention services and so we provide remember that initiative that she said was the e-ha initiative that's that early identification one of the things that we did in san antonio in order to support that initiative was fund a provider and it was the alamo area resource center to do our early intervention and that was done competitively bid and they not only wrote a proposal they wrote a proposal that knocked everybody's socks off and developed a model program for early intervention that has now become a best practices program in the united states so i'm going to uh introduce jesus or they are from the alamo area resource center to talk with you and describe a little bit about their early intervention program and how they link clients to care where is it over there technical problems all right uh my name is jesus or tegan i'm the programs manager right now at the alamo area resource center i've been with arc um five months uh actually as tomorrow six months tomorrow um so as charlene was saying part of um part of what we do as the early intervention um services um i have to say that even before that i do think that um in what we've been hearing today in order for us to really implement this program it is very important to have partnership and collaboration within the community we won't we won't be able to do this program and right now we've been presenting even nationally because we have uh has really impact in the clients that we work with but we won't be able to do that if we don't work closely with the county as the administrator agency with facts actually clinic to provide extra referrals and clear um partnership with them to because um before i understand it was even better because they were on the second floor and we were on the third floor and we can just go you know up and down now we have to cross go across the street in order to get that but if it's if it's about partnership and collaboration that can make this implementation of this program really successful and effective among the different agencies um and in regard to testing which i think that um i want to mention something that is very important uh in the last one of the things that um we have also some programs from dishes in terms of doing prevention and testing and we're actually working very closely with Walgreens for HIV testing uh national testing week on the 27, 28 and 29 and um and again it's about partnership and collaboration and we won't be able to do that if we don't engage on those kind of collaborations and one of the things that struck me about san antonio um as you guys can see i'm no from here um actually from venezuela and it's how we can make routine testing a routine and that's a challenge um we were trying to actually get to do HIV testing at the pride event and it's been quite a challenge we have to create a coalition we've been working very closely to them and we have to be approved in order to be able to do that in a gay pride event in which testing is still a stigma so um so so testing in itself has a little challenge and the eis is okay when these people are actually diagnosed have been positive what it is that we can do to link them immediately to care so um you might and i want to go through very quick um this is the people that should be here this is a present but this is just me right now and actually at the time i was the director of eis which is the early intervention services but you know life has some changes within the agency and now i'm the director of the programs manager but this is in general the alamo resource center um we are spending in 2012 our eis to include testing also in non-traditional locations such as par libraries churches parole boards colleges and university and um this is a little bit of the history of how this program has actually evolved within even within the agency and um and now one of the things that we are doing um because we uh we're really trying to reach the hardest to reach population and it's interesting that you guys mentioned about grinder and about manhunter and about atoms to atoms and all of that one of the things that we're trying to do is really how we can tap into that and one of the things that is happening is that they actually those website takes you down if you start talking too much about hiv prevention they take your profile so one of the things that we're trying to figure out and creating policies internally is that some of the workers that outreach works that we have how they can actually participate in that conversation right so um but you know it's the issue of what picture do you put uh do you put your own picture do you put somebody else's and um so outreach is a big part of yes is how do we go about testing where do we go we actually have like um you call mobile testing we have um in which we go to the park we actually go like three times a week to the different parts in san Antonio where people actually hook up and um but definitely social media is the biggest place for hook up right now and we have to figure out how to do it we're thinking about the idea of young people actually being peers to to be able to themselves be talking to other people but you know there is a lot of training that has to go with that and there is a lot of like you know established boundaries so that they can actually do it themselves um so the goal of EIS in particular is definitely to facilitate early access to medical care and remove the barriers to ensure medical adherence and some of the activities that we have if we have an initial intake and assessment uh case management referrals um employment for all the entitlement program benefits and then targeted outreach um as I mentioned before in particular conventional site for HIV testing and counseling um we are actually trying to get right now into um those um pole dance um strip clubs and particularly to target women and um it's being a little bit of a challenge however it seems like we want to have an open door at least for one to do it as long as before the hours before they start working if we can actually go and do some of the testing to the women and also one of the things that we've been doing is um day labor testing so we're going to these trees and actually trying to test day um day workers one of the things that is happening is that day workers are actually being used as sex workers they're being picked up and instead of doing day work like carpentry or anything like that they're actually being used as sex workers um so that's one of the things that we also target in in testing um this is a lot of specific about the program and I don't want to go over everything but this is intense we have an initial intake and from that we move that into case management and the case management is there's also very intense intense case management we do a curious scale we assess client medical and psychosocial history and develop a service plan and then we try to implement that service plan in a timely manner sometimes we say three months that's the goal however um working with the clients sometimes to keep them into medical adherence it's a challenge itself because of all the barriers so we do referrals to access HIV and medical care and we also apply for entitlement benefits we can move this a little bit along um we go to local bars streets um and then we do the counseling as well and with for HIV testing and I guess that one of the things that is very particular about the EIS program that we have is that they have four main components and one is they have to make a first medical appointment and we try to make sure that they do that they will also have to get an appointment for a mental health and sustained abuse assessment and services they receive also health education and risk reduction class and also a nutrition assessment that we work very closely with the fax clinic to actually do that and um so those are what we call the milestone they need to complete this in order to move either to medical case management or non-medical case management within the agency one of the things that I think that is good about the Alamuera Resource Center um what I call my attention when I start applying for this job is that we have this model of one stop service so people can um and I think you were referring to that right we do have health insurance we do have housing we do have mental health and sustained abuse we actually do have also patient navigators that help actually the clients to navigate the system so that they can be a medical adherence a medication adherence um we also um have um it's a project that is um part of the um UT health science center that we collaborating and it's kind of like a national significant project which is called the women's heart project and um and this is just a specific for women to provide where HIV positive to provide them and follow up with them throughout many years to see where the barriers to care and to health and dealing with the issue of HIV um so we track with primary medical care infection disease which are centromed and fax and we try to figure out in terms of the milestone um when they do the first medical appointment which includes the lab work and meeting with a medical social worker and the second medical appointment is scheduled within two weeks of the first appointment and it's group obtaining the lab and the medication therapy if needed um so again one one of the things that we're trying to do within the EIS program is um really to find out what are the needs of the client what are the barriers we do a very exhaustive assessment and trying to figure out how we can make referrals that can help the client to really overcome the barriers to medical adherence and um we I mean again we do medical history psychological symptoms household dynamics and system use um and then we also have what we call the PTA and we found that this has been very helpful for the clients which is kind of like the peer treatment advocacy and they do a lot of the education to learn about HIV to learn about this risk um to learn about what kind of behaviors um can put them in dangerous and we do also you know HIV one on one medication adherence and um and they do have some kind of like pre and post before the milestone and after the milestone so one of the things sometimes is that we lose um sometimes we lost them and we need to keep track of them and that's a big part important part of the EIS we use Facebook we use all the outreach worker have cell phones and they participate in Facebook and it's incredible the either texting of Facebook is the way that the clients reach us and sometimes if we make a phone call uh home visit um they even say like uh why did you didn't text me so I think that one of the things we also have to become innovated about how we do our reach and how people want to be actually contacted and Facebook is definitely one way that we do it they sometimes talk more on Facebook that even when they are on one on one particularly with the young people um and they'll um they can actually even if they move into medical case management they still can use the PTA program and we have actually most of the actually all the PTAs are bilingual within ARC and we also have women's if they prefer to have women PTAs and then as I say we also refer people to facts for the dietitian and this is something that people that have found very helpful um to have even like this idea that I have a nutrition plan for myself and how that affects my health and um and evidently it's it's something that is part of their um you know understanding how they can actually really be healthier and um and what is the impact that all of that have within their immune system and how they can help in terms of the type of medication that they take um clients are actually tracked up to six months um post transition for medical adherence and one of the things in order to be eligible for EIS and I should have mentioned that before is that you have to be newly diagnosed that newly diagnosed for HIV and all you have to be out of care for more than six months so um those two people are the one that we particularly target so that's kind of like a general um way that how EIS work we get actually um referrals for you know hospital health care and services organization testing sites and um and then they we do the initial intake and then we see either newly diagnosed of out of care and we do the case management and these are here at the four milestones and um and then we actually staff them with the PCM and if we either transfer to medical case management or no medical case management um but they can they could be in the program sometimes for up to a year um sometimes people do the um they want to stay within EIS because they've felt it that EIS help them in that process particularly newly diagnosed but we also kind of trying to reach for you know um self-determinations and self-sufficiency and that's the idea that's the ultimate goal but if they actually relapse and they go out of medical adherence we can actually go back to EIS so this is just to give you a little bit of um who are the people who participate in EIS um 65 percent are Hispanic and 20.72 percent South African American which is up to 85 percent of the population that we serve and then in terms of gender um we have um and the colors are kind of funny here because this seems to be the same you can feel that this is transgender but this is actually males and um and we do have very small percentage of transgender population here and that's definitely the age most of the people is between 25 and 44 years old um 429 clients and uh and this is actually for 2012 and we have um returning to care are actually 40 percent of the people that we have within EIS and also really 60 percent are newly diagnosed and we have 742 positive individuals that came throughout the program last year um again this is a little bit of uh the number of people who of the positive uh who has eights and some of them should be no no no we can so one of the thing about the EIS out of the 742 clients that we have in the program 532 completed in milestone and evidently this has to do with a lot of the intensive case management that we do at the beginning and also the collaboration with the different agencies so that we can really track that person working very closely with FAT and MEX clinic um and again when we refer them to our reach which is around 47 percent um what we mean by refer about our reach is when they actually fell out of medical adherence we have an outreach especially position and that person go after that um and try by any means home visits Facebook um any website that the person has just trying to find that person to bring them back into services and we have just 16 percent of them that actually refuse um and it's 10 percent is people who are in care 10 of them who are actually incarcerated that that's what we have to drop them out of services and this is the CD for counts for them and it seems that most of the people um is their CD for counts are between 350 and 499 as a result of uh so it's also not only the medical adherence but also how their treatment have improved their health and the CD for counts for them I only have 10 minutes that's what it was okay um this is the number of client according to the viral low and and if you see most of the clients their viral lows is zero to 50 so it's very low I guess the part of what since EIS is really it's about medical adherence 83 percent of the people who participate in the program stay under medical adherence um and those who are not in compliant even though it's small we still try to do the outreach part of the program so one of the big thing that we also do is our marketing plan which is something that is very innovated about the EIS uh we have used both shelter junior posters advertising local publication we participate in awareness day and we also try to do something that is more targeted right um we try to look for the zip codes of newly diagnosed in the past three years zip codes of loss of care loss to care population and we demographic of the target population as you guys saw African-Americans and Latinos are the higher portion of this population this is our marketing plan and how it has evolved so far and this is one of our um samples we did it in Spanish and English and we have billboards and we also have it on the boss and you can show the other ones that's the boss shelter this is the junior posters and our program is called thrive the EIS program is called thrive and most of the targeted we target in these areas here on the zip codes of San Antonio on the east and the west side so some of the success can be as definitely attributed to the intensive case management the fact that the outreach is actually targeted uh the cooperation between the different agencies that we work with the program design the treatment advocate program the marketing campaign and um and I think it's also you know we say well is the agency is the agency well it's it's not the agency if actually the clients are the one who wants to participate stay on the medical adherence and find that that's actually a place that they want to continue coming to and they feel that there is being help it's been a help for them so a lot of the responsibility is also on the client um so I think that we have to give credit to that it's not just the Alamoero Resource Center it's also the client being able to participate in the program and that's it yeah um that's that the contact information okay I'd like to share with you because I know we're running close to time is that um on the exhibit table outside you have many things that we have for physicians and physicians offices any public area that we can put them on barber shops beauty shops who cares any place where we can get in and get a foot in we have our resource guides the big one they are bilingual they're red you've got one right there you've got the many resource guides those are done for clients because clients don't be well don't be walking around carrying a big book so those are really for case managers and to be placed in doctor's offices then we have pill boxes in order they're red out there if you need them for your clients or your patients take them that's where they're there for this year our program at the Ryan White program got feedback and they said the pill boxes are real nice the color is real pretty but you only have enough for one pill you don't have the morning and the evening we want the boxes that are square that have the yes and so we're going okay next order we need to redo that because basically we're here to be able to give you the tools that you need we also have out there English health diaries and Spanish health diaries where people can write down their cd4 count their viral load their next appointment and it also gives helpful hints about as Jesus said some medical some nutritional issues that they may want to talk about you can write down your questions for your doctor on the next visit etc so we do those we also have little cards out there that are saying stay negative and that's if you've tested and you've tested negative how to stay negative and with the behavior if you go in to test almost as your behavior to going you continue to do the risky behaviors but you want to continue to test it shows you where all the testing sites are and it really tries to encourage you to also stop your risking behaviors and the other part that we do is we have condom trainings I'm known affectionately as the condom lady anybody who needs condoms in the city of san Antonio and wants them free I will give them to them and we have both male and female condoms available and it was uncanny to me that about two years ago two to three years ago we held the first condom training and we had professionals nurses coming in and outreach workers when I started when the epidemic I'm 67 when I started with the epidemic in the mid 80s that was the only tool we had that was before antiretroviral therapy and the only tool you had for behavior change is to convince somebody to use a condom and so condoms were my life that was what you did in public health and that's the oh you had to be good at it we did it on bananas on cucumbers we did demonstrations on anything that would stand up straight right absolutely and I'm not afraid to say that and now we have the female condom and I was very surprised at how many health professionals have never seen a female condom much less know how to tell the women to use it and what happens in that when somebody asked us about these rising syphilis I would give you my answer and my answer is African-American and Latino women do not know how to ask their man tell me where your penis has been they cannot do that we haven't engaged in the skills we haven't done enough sexual health in our communities for women to be empowered in order to do that so until latina and african-american women in our communities who are suffering disproportionately from these rates of stds can ask a man tell me where your penis has been and not get caught up because of it then then we would have come to a place and one of the things that we can teach them is how to use the female condom as another alternative sometimes the price is prohibitive so that's why we buy them and we give them out free there are also materials distribute distribution forms we give out the hand sanitizers we give out the key chains because some of the community offense we go to won't allow us to distribute condoms churches high schools places like that so we still want to have the kids to make sure that they know that they can do hiv 210.org so if you've got an event coming up if you want some things for your office or if you don't know somebody who owns a beauty shop a barbershop any place where people gather and the last thing that we did was exceedingly innovative I think and that is our photo novella and this is an old cultural artifact of of my generation in the latino community and some of them remember your grandmothers and your mothers reading this was before telenovela was really popular was really popular they used to read the photo novella and we have them for we divided them in three areas this is a photo novella for jovencitas and that is for young women and it's about a boy and a girl trying to negotiate it's english on one side spanish on the other we did focus groups with young girls and what they all say is he's the love of my life of course I'm going to have sex with him without a condom if that's what he's required and because they don't know how to love themselves first the theme of this is a dialogue around a girl and a young man having that encounter with a very different with her saying I love you but I won't sleep with you without a condom and it also gives you where to go test it and at the end he walks away and I like the ending on this one because it says it shows her using the app on the the texting going back and forth and I think his name is Marco and because she's saying she wants to negotiate condom usage and at the back he said she said I guess I lost him and then at the end he comes back and he said you know you are worth it it says it says marcus says sorry for how I acted yesterday k if I meet you at your house I want to talk and the text back is apology accepted see you there so there is happy endings when young women can stand their ground and so this is a very positive this is the one now we got some feedback on this one because this one is for the damas and those are you know you've gone to the restrooms and say damas women's restroom this is for women middle-aged women and when they pick it up what does it look like to you a von book exactly and so they're going you know you can put you can put this you can put this in the in the doctor's waiting room and they'll pick it up and going oh this is something you know this is something interesting to read this is something sexy and they read it and look what it says it has condoms in it it's like how you attach it to your purse you know how you can do the condom things and it's really set up in the storyboard is set up very interesting and how women can take control of their health and it talks openly about condoms and it talks openly about where you can go and get resources and these colors here were very significant to our focus group we went through in health literacy we went through a lot of community input in order to this is a product of the san antonio community and the last one we have the star in our midst and the last one yes lucia is she'll do autographs by the way i think she's charging five dollars all proceeds go to never mind and so lucia's yeah i'll just go to lucia she needs a new handbag now um and then um um liz who was here oh there you are you're in a mood liz mama is the other one on here and liz's mama is a breast cancer survivor and so they were needed to what we call lonias yours truly is one too and it's just like there because of viagra we're having sex i know that disappoints many of our children but we are anyway and so we went to uh i think they were getting ready to do the shooting of this and needed another partner for lucia to be talking to liz's mother said i don't know anything about hiv it was a beautiful sharing of why would i talk about that i'm an older woman we don't talk about those things i mean i can talk to you about breast cancer because i'm a survivor but not sexual things and then when liz shared with her to her mama mama just like you want people to understand about breast cancer to get checked and prevention and her and why not for hiv and her mother said you know mija you're right and so it's liz's mama who is the other person on this these were very personal to us because they came from our community that they're not going to be any good unless you help us get them out to community they don't need to go to those who are already hiv positive they need to go in your doctor's offices they need to go in beauty shops uh laundromats they need to go anywhere you can help us colleges university to get them out and they're totally bilingual and they have all the resources for where you can get tested so at the county what we try to do with our ryan white program is work with partners and one of our largest partner is the hiv syphilis prevention task force if you have time we meet the first wednesday of every month to educate ourselves to develop the policies and the procedures to do the networking to do community events in order to do something about the problem in san antonio so it's the hiv syphilis testing task force and then you have all the programs uh that we fund and i think the panel here proves it's not one person doing it alone it is in collaboration and cooperation and i will tell you that dishes and several other people including the federal government have come down and saying in most communities throughout the united states because there is funding involved people are very very competitive and they don't talk to each other and they don't form coalitions and don't do collaborations well and they want to know what our secret is and i say we feed people at our meetings never mind that's what i'm here yeah she's got our provider has noticed a lot of a large increase in just in general people coming across from peteris because of the there's quite a bit of violence in peteris right now so another thing that's happened in ego pass is a lot of people are tested really late so some of the people who've tested have had hiv probably for a very very long time at least a third if not greater closer to 40 percent in ego pass are coming in with AIDS defining conditions so they're just really late to care and another thing is the state of texas actually started counting cases differently so instead of looking at where the person was diagnosed initially they're looking at where that person lives now so what's going on is a lot of folks in ego pass have moved there to go back home because they get so sick that they want to go home so they've left the and moved to dallas they've moved we do have some immigrant migrant workers who have hiv in ego pass so sometimes they could have been diagnosed in you know michigan or wherever and now they come back home because they're so sick that's what where a lot of the happens in ego pass oh yeah yeah exactly and you know what our detention centers where they're located in and victoria actually has a much better late to care rate so theirs is about 20 25 percent so fewer people are in victoria are being tested super late the bad thing about victoria is we don't find testing in victoria we do find hiv testing in ego pass because of that late to care problem victoria we don't and there's very limited hiv testing there they do have a good dis worker out there and because they did have a syphilis outbreak a few years ago in victoria and she worked very she works very closely with our agency to do partner notification and follow up they victoria did recently have four newly diagnosed younger people one uh and they are still experiencing late to care um what uh because i think one of them had actually passed away within three months of diagnosis um there's another one that in the ego pass area the initiative they're going to start with their is going to the people for child camps because constitutes are now coming in or sex workers are now coming in both times are coming in as well as substance abuse in order to service the people that are in the shelf shelf for uh uh areas and that's very much in that rural area around the world and so that those we may see as five our victoria and ego pass areas are diametrically opposed they're quite different areas our victoria area is actually the highest income of our three areas we have quite a few clients out there who have some fairly high incomes and a lot of them are working and they have a much more diverse population in victoria they actually have people who are who've emigrated from africa who've emigrated from vietnam and all sorts of other places and uh so that's one thing and uh ego pass is fairly is our most our poorest area by far and there's very limited resources in ego pass victoria actually has a fairly good medical center ego pass is very limited in the resources that they have uh so actually they receive quite a bit more money than victoria because of the rate of poverty which is i think sion has just a few closing resources for you yeah just just a couple of things because we're really with the whole syphilis thing comes that whole congenital piece and the number of babies that we actually lost last year as a result of so what i brought with me was the press release that dr schlinker put out on january the ninth i have copies of that and then also the letter that he drafted to the providers in the area trying to encourage that third trimester uh testing we are already at case five for congenital for this year that's way too many i will so right here i need to bring it up higher yes it's picture almost done i just have a few things we want to wrap up i wanted to point out inside the portfolios that we left at all the tables we had materials um some of them were actually to help you implement routine testing or else to share with people who are interested in implementing routine testing all the materials are available from dshs the warehouse for free the only one that is not is the coding guide it was published by the am a and the american association of hiv medicine so but we have provided these for you to use um the ones that have been very popular especially for healthcare settings is this make hiv routine testing in your practice because it speaks directly to the medical provider um also people are very interested in the data so this is a snapshot the data is from um through 2011 we'll be updating this probably by the end of the summer for the 2012 data and then of course we all need to be protected by the law so it goes into the details of that inside the pockets we just created a new um design for education the first one is for the provider and inside it has a list of the codes so if they want to bill this is the code they would give it to their they can't charge capture people with the ones that do the billing not the ones that get the reimbursement um this is for your patient um we were just at the text med and talked with a lot of providers and this not just for the patients i think it's a great thing for the providers who aren't as well-versed it has a lot of the frequently asked questions well they're not that many what are the symptoms how can i protect myself and loved ones how do i how often do i get tested and what if i'm positive so it just has a few questions with answers that helps the provider be a little more um verse to talk to their patients about hiv and the importance of routine testing also in your um packet we had the evaluation i just want to address that quickly um we applied for continuing education credits only for dr holly's talk dr mccarthy and then the panel so that hopefully will explain why there aren't other questions we did the application through our dshf ce office and they kind of direct our evaluation so please if there's anything else about the meeting that you want to share about the other presenters i know dr mangler did a great job with the um regional data here talked about being in you know sub-center in africa the world health organization you know please make those comments we would we'd love to hear that and then we can also help us with planning so if you're requesting continuing education be sure to complete this and leave it on the table as you leave on that where you signed in to register and then last is this handout it says routine hiv testing as a standard of care implementation essentials and has our website we have a recently released website specifically for routine testing at dshs we've really had prevention services std i mean we never had anything for routine testing in medical health care settings so now we do and this short little slide basically i've given you all the things you would want to consider to plan to implement a routine testing program we've added the links the hot links if you wanted to go straight to the health and safety code if you want to go straight to the cdc guidelines we have all of those links as well as some of the other useful handouts materials that you would share with leadership that would make the decisions rather to support it or not so if we just want to move along just to bring it back the source of all hiv tests and hiv positives that have been identified this is old the national health interview survey from 2006 and then the supplement of the hiv aid surveillance from 2000-2003 i wish someone would update it but you can see the majority of the test are done in medical settings we've got your private doctor the hospital ed the outpatient and community health clinic 53 of the test 18 and 5 percent and then when you're looking at the positives that are identified 17 by the private doctor 27 in your hospital ed outpatient setting and then 21 in your community clinic so really that is the place to test that's where people are being identified and the beauty of that is they are connected with that health care provider i was having a question about the early intervention services but it's more of a a program to help people stay into care but i keep hearing over and over that when people have um a diagnosis of hiv that first appointment is just to have blood work done the next appointment might be to talk to um a case manager about what's going to go on but it's not until the third appointment or after that they actually meet with the health care provider talking to dr holly about that it's like it's that whole development developing a relationship that trust and sometimes the reason people never really engage in care or they don't stay in it is because maybe if they had had that initial meeting with their doctor build that relationship that trust for them to instill in them why it's important to stay in care we might have more people that stay in care so that is something i think to talk about to think about i know a lot of it has to do with funding you know how many minutes does this doctor have to be able to spend with a patient but sometimes i think especially with public health issues that we kind of need to rethink that and who knows we might change the world so next slide um i wanted to draw your attention i don't know if any of you saw the new york times article last sunday it's called people think it's over spare death aging people with hiv struggle to live it was a very interesting article because it discusses the lives of two people who were identified early in the epidemic and basically when they were diagnosed with AIDS they were basically trained to think that they were going to die well they lived long enough that they went into the different clinical trials the different medications and they lived and then along comes you know 1996 when the miracle drugs come and now it's like they had come to a point where they were going to close their life they had done everything they wanted to and it's like oh i'm going to live so now what do i do but because of that they are aging and they have many of the same diseases that anyone who ages has a next um cancer heart disease especially cancer in patients with hiv aids non-Hodgkin's lymphoma is very common just they are typically it's an inflammatory disease so i think that art the antiretroviral treatment it causes a lot of inflammation that also accompanies age so they do have these same illnesses sometimes a little bit earlier than people are as they age but cancer heart disease strokes lung disease kidney failure diabetes hello high blood pressure thyroid arthritis the neurocognitive decline and memory loss and then just the general weakness fatigue depression and anxiety and you could talk about any person as they're aging and as they get older and older these are common things well people living with hiv aids it's even more so because they have the hiv to make it more complicated so the importance i think i feel is that they do engage in medical care that they go to a physician who can manage all of these you know they're aware of it and they have relationships with specialists that they can refer them out to because they're going to live a long time and you want them to have a healthy life to not you know compromise their health so that's just a little um plug on that but i think it's a really good article it'll be worth it was um the i guess in the sunday magazine june 3rd of the new york times so next um i just wonder i think we said this before that it's a physician's duty to promote the patient's welfare and to improve the public's health so it's fostered through routinely testing your adult patients for hiv and the medical community recognize this back in 2006 i don't know that everyone got the message and so it's the people who are working with hiv and the prevention and care services that we need to continue to share this message that it is it's part of medicine hiv is a chronic disease it's it's treatable you need to help your patients manage their their their health so when we are thinking about implementing routine testing the first thing you want to ask yourself do i serve the population that needs to be tested so what is the age um i was i think dr mccarthy was talking about the people he was going to do some targeted testing by zip code the um to determine if you have a 0.1 percent or higher they say that you need to test over 4 000 patients to really get that that good number it's a statistically sound number that's saying you're testing enough people to say no i don't have enough people so i don't need to do routine testing i'll just do based on my risk how i interview my clients but you know identifying who that population is and if it's positive you know to go ahead and implement testing um the patient consent process has always been something that people at the beginning of a program they want to know well what do we do how do we get in our general consent some of the programs they do signage some actually write in the hiv test and their general consent others just say you know this is they've consented to any of the care that i recommend i recommend hiv testing so they take care of it that way the important piece is that it's documented in the chart that they were informed next um testing technology dr mccarthy also shared the story of the point of care testing and some it takes so much um individual oversight to process one test that if you're seeing a lot of patients a lot of rapid turnover you probably don't have the dedicated staff to be doing that what we have learned um with bang per buck the conventional blood draw if you're drawing blood you're getting a lot of other stuff a cbc liver enzymes cholesterol it's one extra tube of blood some they don't even need a whole you know if they're doing a red top they sometimes i call it the speckle top it's from the same tube and you know you're only pulling out you know a couple of milliliters you can have enough blood to run the sample twice as well as pull enough to do we used to do the western block now we're doing the multi spot which i don't think even maybe even less blood so you want to make sure you have enough sample to do the positive the first preliminary positive confirm it then enough for your confirmatory and then in case it's indeterminate then you'd want enough to be able to send to have a sample for the the nat the rna or dna to determine if you have an acute case so that's something you always want to think about is you know how you know my staff and my have enough to actually process the point of care is it cost effective or do i want to do the conventional um central mad they send their stuff to lab core they have a stat established population so they can just send them a letter we um have call us to make an appointment to come in and discuss your lab lab results um dr McCarthy hate i'm going back to him for everything but yes we have a lot of practices that they want it to be physician driven as he said sometimes the nurses are the ones who have a lot of interaction they have a little more time with the patients so they tend to be the ones who can say have you ever been tested we're recommending that everyone gets tested do you have any questions so then too they intend to cross the t's and dot the i's for the doctors they work with so sometimes a nurse servant model may be a little more practical i'm delivering test results to patients how are you going to do that i know that was a lot of questions memorial herman a lot they do have a very tight relationship with the city of houston and the dis go out some of our hospitals they actually have a caseworker a medical caseworker on staff all the time 24 seven they do the delivery of the results some even have like um not a priest a minister whoever's there to help with the psych patients for counseling they're there to help out others have their coordinator who that is what they do that's their specialty so they are there they're available or they have someone back up or they use flex time you know i had to go in and meet a patient at 2am i was there till five so i'm not going to come into work tomorrow until three o'clock but so that somebody can give them that face-to-face notification of their positive test results i'm linking in confirming the care of the the patients some hospitals are not affiliated with the fax clinic like at university health so what do they do we have a perfect example in bowmont texas dr holly but they baptist hospital didn't have a clinic they're just a sort of like memorial herman a non-profit um private hospital so they've made strong partnerships with their local department of health they have their ryan white funded care services they've partnered with the drug abuse and mental health program and so they they work together they meet monthly to discuss you know who how many people have been diagnosed positive if they've linked to care they they stay in touch to go yes the woman that was deaf and had cancer yes she's made her appointments and she's been in care now for six months i mean and they actually have such good relationships and since they do make that effort to meet every month they do they see how many are engaged in care and if someone misses an appointment they're small enough community their partnership is so tight that they are able to go and follow up with their patients smaller community and a big huge metropolitan areas it's very hard to do that but they're they work on that partnership monthly the disease disease intervention specialists are especially helpful in those settings where you don't have um someone who's on payroll to do that they're not there 24 seven like a hospital might and then reporting positive cases of the local health department um dr holly had a great system for assist automatic one thing in texas we do have that redundant requirement so the lab if it's sent off to a lab they have to report to the state as well so we do have the physician or whoever they designate within their facility to report as well as the lab so we know that if somebody forgot paper got lost that there's going to be redundant reporting um sustaining routine testing um it's so important to have a champion when i met dr holly i was in bowmont trying to find the ceo at the hospital because we learned that if you go at the top if that if that leader buys into it it's going to trickle down if you go in at the back door or across the street it's really hard to have that communication to the people in the departments that need to run the program so i met him and he called up the ceo and said hey will you call talk with miss clark and he said he would and it was just it was that easy he they had a meeting they said is this important is it a chronic disease they agreed it was a chronic disease and i got a phone call from the director of the emergency department and said they told me to call you what do we need to do so it was like you know and that's when we hear the stories um lisa fits patrick she's a physician in washington dc she's been very active in the hiv aids field the community and that's what she's saying to have successful programs you have to have the leadership at the top because they're the ones who say yes it's our mission yes we're going to devote the time the energy it's something that we care about and so that's how they've been successful how they're able to make changes if something in the program isn't working you've got the support at the very top it's um it's sound it's very simple but it's very very hard to get that connection and the time for that person to to listen to you um the it coding and changes i know we have mixed feelings about that um if we could all have our custom emr life would be great um but tweaking the programs if you can actually i know matt's no longer here but he's with the university health and when he finally found the right person at uhs to talk to about pulling together the right data to submit to the state his life became much easier and we got our data much more quickly so it's navigating these huge bureaucratic systems and finding the people to talk to which is very hard but um if you can get that person at the top they know who all to go to they'll give you a name it seems to be much easier um billing coding and reimbursement with the grade a recommendation we hope that life will be a little easier for doing routine testing we won't say that i can't do this for free we can't take the cost we can't cover it so we hope that's going to be something that's going to change um training on this sheet here we do have some links to available trainings because you're constantly having to train your staff we know that at uhs they have residents we've got interns that are just going through the emergency department you constantly change people you know they're they may want to move to take care of an aging parent they get married they move away you're always going to have new people in and having a a routine training that some of our programs are starting a web-based training so basically if someone new they can take this 20-minute web-based training to just give you an overview of the program some of them are doing like employee orientations so there are just these wrote trainings pam green at memorial herman she meets every month with the different nursing staffs at all the different hospitals and she has a little training powerpoint and she just goes through it it's i think about 10 minutes if she just goes over it because there's always going to be one or two new nurses on staff she shows them the testing results how they compare their site to all the others and just really keeps them engaged it's kind of a constant until it becomes totally routine and people go yeah i'm going to do a hiv test just like blood fresher you constantly need to keep communicating with the people that are performing the direct services and then quality assurance activities we just added a new qa plan that we've given to our sites and we were a little worried because nobody wants to talk about doing quality assurance and getting monitored but i got the opposite the people embraced it because it was like a roadmap here are the best practices here are the the links to help support us to get there one of them went you know i didn't even think about training we've just been trying to tell people to do more testing so it gave them a way to just step back and look at the whole program and fill in where they had gaps and we're always there to help i mean that's our job we're a little passionate about it but believe that you know whatever we know we want to share with you to help you have a successful program because the more people we test the positives get into care we know that we're going to decrease the transmission rate and lower your community viral load you'll have a much healthier community more money to spend on other chronic disease and so that's kind of what this is for to help you your roadmap and our website and i think that might well ditto i think already said that so i one thing i didn't say i think what i was supposed to put there is i i quote her all the time lisa fits patrick she actually was over the pit far when haydie had the um earthquakes and but she's been very much involved in hiv aids care and she was interviewed and her thing is that she says if you can get people living with hiv aids into care any care we can prevent aids so if you can get someone early or even someone who hasn't advanced to aids if you can get them into care and healthy they may never ever develop into you know having an aids diagnosis so i think that's a very powerful statement and the potential that we have now with all the things that have occurred i'd say this last year is is making us get that much closer to it so hopefully you have getting just have a different view of routine testing what it is and that it's it is just as important we're not saying that the counseling and testing or the going out for the different health fairs or testing days that is really important but routine testing and health care settings are for those people who think i'm not at risk i don't know anyone who has hiv it wouldn't be me or for the doctors that go not my patients but as we saw that's where the majority of the people are being tested and identified as positive are in that that health care setting i think that's all i had to say if y'all have any questions let us know our contact information we're going to be providing the slides information for a couple of reasons we want to keep you updated on any questions that you might have in regards to the information that was given to you today with regards to your CT scan anything like that that we need to follow up with you after this summit um you notice that we have cameras here and that's actually a sponsorship donation by now pacca.org so we have been able to livestream the presentation today for those people that were not able to make it at the last minute we had a couple of decisions that were not called away because it's come at the last minute that they weren't able to at least visit us online if you didn't get the privilege of giving this to you that i did but um they have some of the information we will also be sending you the links to that um so for those of you that want to share the information to your colleagues that come to today we'll send you that link so you can get that out and we can't just give you the information by the presenter today to provide you with the link to the information and dr. manlin has also provided us the permission to send you his powerpoint to live so that was the first presentation from senator general hall and so we have your contact information up front we'll be able to send that to you um there are a lot of medals because our operations senator right over there really needs to be signed and then the next benefit is our programs for our program manager and uh i'm listed and so we will be very happy to see you to to help you continue to provide information um through the planning committee after this uh um there's ended up having a happy public meeting today again thank you for being here our data coordinator says we are closest to our data and we met people who met something that's part of our grant funding because that we had to send a job to help them put together a slide so she's so fortunate and she's someone of